hyperthyroidism. defintion tttthyrotoxicosis iiiincreased thyroid hormone levels with biological...
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Hyperthyroidism Hyperthyroidism
Defintion Defintion
THYROTOXICOSISTHYROTOXICOSIS Increased thyroid hormone levels Increased thyroid hormone levels
with biological effects on tissues with biological effects on tissues and systems and systems
HYPERTIROIDISMHYPERTIROIDISM Hyperfunction of thyroid glandHyperfunction of thyroid gland
HistoryHistory Have described different forms of Have described different forms of
hyperthyroidism hyperthyroidism Parry (1786),Parry (1786), Flajani (1808), Flajani (1808), Graves (1835),Graves (1835), Basedow (1840),Basedow (1840), Moebius (1886), Moebius (1886), Plummer (1913 – adenomul toxic), Plummer (1913 – adenomul toxic), Adams, Purves, Mc Kenzie (1956 – long-acting Adams, Purves, Mc Kenzie (1956 – long-acting
thyroid stimulator immunoglobulins – LATS)thyroid stimulator immunoglobulins – LATS)
fT4
fT3
T4
T3
TRH
T4
T3TBG
Thyrotropic axe
I-MIT
DITI2
thyroglobulin
fT4
fT3
T4
T3
I -
piytuitary
I- T4
T3
I-
TSHTSH
fT4
fT3
TRH
HYPERTIROIDISMEtiolology : incidenceEtiolology : incidence
Graves diseaseGraves disease- < 40 ani< 40 ani- f / b = 10 / 1f / b = 10 / 1
AutonomicAutonomic- >40 ani- >40 ani- b=f- b=f
other (< 1%)other (< 1%)
HYPERTIROIDISMHYPERTIROIDISMMost frequent formsMost frequent forms
T4 T4 T4
TSH TSH TSH
Basedow-Graves diseaseBasedow-Graves disease Toxic adenoma PlummerToxic adenoma Plummer Toxic multinodular goiterToxic multinodular goiter
Hypertiroidism – etiologyHypertiroidism – etiologyA. tirotoxicosis with hyperthyroidismA. tirotoxicosis with hyperthyroidism
1.1. Thyroid stimulationThyroid stimulation TSITSI
Graves diseaseGraves disease TSHTSH thyrotropinomathyrotropinoma
Resistance to thryoid Resistance to thryoid hormone action hormone action Refetoff syndromesRefetoff syndromes
Human Chorionc Human Chorionc GonadotropinGonadotropin Trophoblastic tumorsTrophoblastic tumors hiperemesis gravidarumhiperemesis gravidarum
2.2. Autonomous thyroid Autonomous thyroid functionfunction
Toxic adenomaToxic adenoma Toxic multinodular goiterToxic multinodular goiter Non-autoimmune difuse Non-autoimmune difuse
hyperthyroidism(familiala, hyperthyroidism(familiala, sporadic?)sporadic?)
Thyroid carcinoma follicularThyroid carcinoma follicular struma ovariistruma ovarii
3.3. Iodine inducedIodine induced Jod-BasedowJod-Basedow
Iodine contrast media, amiodarone (thyroid excess and Iodine contrast media, amiodarone (thyroid excess and autonomous thyroid function)autonomous thyroid function)
Hypertiroidism - etiologyHypertiroidism - etiology
B. B. Thyrotoxicosis without hyperfunction of Thyrotoxicosis without hyperfunction of the thyroid glandthe thyroid gland
4. Distruction 4. Distruction thyroiditisthyroiditis
subacute de Quervain thyroiditissubacute de Quervain thyroiditis Silent thyroiditisSilent thyroiditis
Drug induced (amiodarone, interferon-alfa)Drug induced (amiodarone, interferon-alfa) Irradiation, Irradiation,
5. External intake5. External intake IatrogenicIatrogenic FactitiaFactitia foods (« hamburger thyrotoxicosis »)foods (« hamburger thyrotoxicosis »)
HYPERTIROIDISM / HYPERTIROIDISM / THYROTOXICOSISTHYROTOXICOSIS
signs and symptomssigns and symptoms Simptoms due to increased number of Simptoms due to increased number of
cathecolamine receptorscathecolamine receptors palpitation (tachicardia, atrial fibrilation)palpitation (tachicardia, atrial fibrilation) Increasd perspirationIncreasd perspiration tremor , hiperreflexia, eyelids retractiontremor , hiperreflexia, eyelids retraction
Simptoms due to metabolic actons of thyroid Simptoms due to metabolic actons of thyroid hormoneshormones Weight loss with increased appetite , decreased fat and Weight loss with increased appetite , decreased fat and
muscle mass muscle mass termofobiatermofobia Warm skin, fine, moist; onicholisisWarm skin, fine, moist; onicholisis Muscle weakness, Muscle weakness, osteoporosisosteoporosis Menstrual problems in women and gynecomastia in menMenstrual problems in women and gynecomastia in men
Simptoms induced by thyrpid hormone Simptoms induced by thyrpid hormone effects on central nervous systemeffects on central nervous system Nervousness , irritability, psychological labillity, Nervousness , irritability, psychological labillity,
Clinical signsClinical signs
9991
898988
8582
7570
65
5435
33
0 25 50 75 100
frequent stoolpretibial oedemaophtalmopathyincreased appetiteweakness Dyspneatachicardia82 weight lossastenia PalpitatiitermofobiaHipersudatie nervousness
Clinical symptomsClinical symptoms
100
100
97
97
77
71
10
10
10
0 20 40 60 80 100
gynecomastia
splenomegaly
fibrilation
eye symptoms
thyroid trill
Tremor
skin manifestations
goiter
tachicardia
Hypertiroidism - simptomsHypertiroidism - simptomsSIGNSSIGNS CAUSECAUSE
Thyroid Thyroid
Diffuse goiterDiffuse goiter Graves’ disease, autoimmune Graves’ disease, autoimmune thyroiditis with thyrotoxicosisthyroiditis with thyrotoxicosis
Uninodular goiterUninodular goiter Thyroid autonomyThyroid autonomy
Multinodular Multinodular goitergoiter
Thyroid autonomyThyroid autonomy
Non-palpable Non-palpable thyroidthyroid
Exogenous thyroid hormonesExogenous thyroid hormones
Painfull thyroidPainfull thyroid Subacute thyroiditisSubacute thyroiditis
Associated signsAssociated signs
OphtalmopatyOphtalmopaty Graves’ diseaseGraves’ disease
Pretibial Pretibial mixoedemamixoedema
Graves’ diseaseGraves’ disease
AcropachyAcropachy Graves diseaseGraves disease
Cardio-vascular signs and symptomsCardio-vascular signs and symptoms
signssigns Tachicardis, continous, Tachicardis, continous, nocturnalnocturnal
+ effort associated + effort associated dyspneadyspnea
Systolic HypertensionSystolic Hypertension Increased cardiac outputIncreased cardiac output
FCFC peripheral resistanceperipheral resistance miocardial contractilitymiocardial contractility
CardiotireosisCardiotireosis Atrial fibrilation Atrial fibrilation : 10%: 10%
Rarely < 40 aniRarely < 40 ani Corrected by euthyroid Corrected by euthyroid
statestate Anticoagulant treatmentAnticoagulant treatment Embolic risk (8%)Embolic risk (8%)
Congestive hearth failureCongestive hearth failure Fibrilation, Fibrilation, Aged patientsAged patients
Worsening coronary hearth Worsening coronary hearth diseasedisease
Neuro muscular signsNeuro muscular signs Nervosness, Nervosness,
irritability, irritability, Emotional Emotional
disturbance disturbance Disturbance of Disturbance of
attention and mood. attention and mood. Pseudo psychotic Pseudo psychotic
formsforms TremorTremor
Muscle weakness Muscle weakness Rapid reflexes, Rapid reflexes, Amiotrophy Amiotrophy
(pseudo miopathic (pseudo miopathic forms)forms)
Hypokaliemic Hypokaliemic periodic paralysisperiodic paralysis
Digestive Digestive signssigns
Tranzit accelerat Tranzit accelerat (motor)(motor) pseudodiaree = poli pseudodiaree = poli
exoneratieexoneratie Anomalii hepatice Anomalii hepatice
Icter, citoliza, Icter, citoliza, hipocolesterolemiehipocolesterolemie
menmen gynecomastia gynecomastia
(40%) (40%) Erectile dysfunctionErectile dysfunction infertilityinfertility
womenwomen Menstrual Menstrual
abnormalitiesabnormalities disovulationdisovulation
Genital Genital abnormalitiesabnormalities
Bone abnormalitiesBone abnormalities Decreased BMD Decreased BMD : :
distruction>formatidistruction>formationon
Spontaneous Spontaneous fracturesfractures
Hypercalcemia, Hypercalcemia, hypercalciuriahypercalciuria
alkaline alkaline phosphatase and phosphatase and osteocalcin osteocalcin
Skin problemsSkin problems pruritus pruritus Localized edema Localized edema Alopecia Alopecia
Metabolic Metabolic abnormalitiesabnormalities
HypocholesterolemiaHypocholesterolemia Hyperglicemie, Hyperglicemie,
worsening of diabetes worsening of diabetes mellitusmellitus
Positive diagnosisPositive diagnosis Clincal signs and symptomsClincal signs and symptoms TSH: suppressed (TSH: suppressed (excepton TSH-secreting pituitary excepton TSH-secreting pituitary
adenoma)adenoma)
FT4 and/or FT3FT4 and/or FT3 Etiologic diagnosisEtiologic diagnosis
historyhistory pregnancypregnancy Painfull thyroidPainfull thyroid drugsdrugs
Clinical signs Clinical signs goitergoiter Extrathyroidal signsExtrathyroidal signs
TSH receptor stimulating immunoglobulins (TRAb)TSH receptor stimulating immunoglobulins (TRAb) ScintigraphyScintigraphy Urinary iodineUrinary iodine
HYPERTIROIDISM HYPERTIROIDISM Peripheral metabolismPeripheral metabolism
Parameter Parameter HypertiroidiHypertiroidism sm
HypotiroidisHypotiroidism m
Basal metabolic rateBasal metabolic rate
CholesteroleCholesterole
SHBGSHBG
OsteocalcinOsteocalcin
OH-prolineOH-proline
PyridinolinePyridinoline
Deep tendon reflexDeep tendon reflex < 240 ms< 240 ms > 360 ms> 360 ms
Qkd intervalQkd interval
HYPERTIROIDISM / TIROTOXICOSISHYPERTIROIDISM / TIROTOXICOSISParaclinical diagnosisParaclinical diagnosis
TSH, fT4
TSH↓, fT4↑ TSH↓, fT4= TSH ↑, fT4↑
Hyipertiroidism
Exoftalmie +
TS-Ab +
Graves’s disease
Exophtalmos -
UltrasoundScintigram I123
TS-Ab
hypoechoicTS-Ab +
Multiplee hot nodulesTS-Ab -
Hypoechoic thyroidTS-Ab -
Toxic adenomaToxic multinodular goiter
Subacute thyroiditisHashimoto’s thyroiditis
Jod-BasedowTirotoxicosis factitiaStruma ovarii (rarely)
fT3
fT3↑T3 tirotoxicosis fT3↓
Euthyroid sick syndromeCritical diseases
Dopamine,
TSH adenomaSyndrome Refetoff
HYPERTIROIDIS / THIROTOXICOSISHYPERTIROIDIS / THIROTOXICOSISImagery: Graves’diseaseImagery: Graves’disease
Thyroid ultrasoundThyroid ultrasound
HYPERTIROIDISM / THYROTOXICOSISHYPERTIROIDISM / THYROTOXICOSIS
Imagery : toxic adenomaImagery : toxic adenoma
Thyroid ultrasoundThyroid ultrasoundScintigramScintigram
T4
TSH Studer Wyss PTU
HYPERTIROIDISM / THYROTOXICOSISHYPERTIROIDISM / THYROTOXICOSIS tests: toxic adenomatests: toxic adenoma
T4
TSH Studer Wyss PTU
Querido TSH
TSH
HYPERTIROIDISM / THYROTOXICOSISHYPERTIROIDISM / THYROTOXICOSIS tests: toxic adenomatests: toxic adenoma
T4
TSH Studer Wyss PTU
Querido TSH
Werner fT4
fT4
HYPERTIROIDISM / THYROTOXICOSISHYPERTIROIDISM / THYROTOXICOSIS tests: toxic adenomatests: toxic adenoma
HYPERTIROIDISM / THYROTOXICOSISHYPERTIROIDISM / THYROTOXICOSISComplicationsComplications
HearthHearth atrial fibrilation resistant to treatmentatrial fibrilation resistant to treatment hyperkinetic hearth failurehyperkinetic hearth failure
Infertility / amenorrheaInfertility / amenorrhea OsteoporosisOsteoporosis (postmenopausal) (postmenopausal) Thyrotoxic periodic paralysisThyrotoxic periodic paralysis
flaccid paralysis and hypokalemiaflaccid paralysis and hypokalemia asian menasian men reversible on treatmentreversible on treatment
Apathetic hyperthyroidismApathetic hyperthyroidism Aging patientsAging patients
EtiologyEtiology determinant factorsdeterminant factors
Undertreated thyrotoxicosis Undertreated thyrotoxicosis Recently developed untreated Recently developed untreated
hyperthyroidismhyperthyroidism Precipitating factorsPrecipitating factors medicalmedical
infecţionsinfecţionsDiabetic ketoacidosisDiabetic ketoacidosisLung embolismLung embolismLabor or pregnancyLabor or pregnancyPremature stopping treatmentPremature stopping treatmentII131 treatment131 treatment
surgerysurgery
Thyrotoxic crisis (thyrotoxic storm)Thyrotoxic crisis (thyrotoxic storm)
Thyrotoxic crisisThyrotoxic crisis
severe signs and symptoms of severe signs and symptoms of thyrotoxicosis thyrotoxicosis
severe hipermetabolismsevere hipermetabolismfever fever
overover >38 >38ooC (til 41-42C (til 41-42ooC)C)Neuro-psychological symptoms Neuro-psychological symptoms
““thyrotoxic encephalopathy" -thyrotoxic encephalopathy" -cardio-vascular symptomscardio-vascular symptoms
tachicardia - >140/min, tachicardia - >140/min, arhitmias (atrial fibrillation )arhitmias (atrial fibrillation )Hearth failure (left, global)Hearth failure (left, global)Variations of arterial blood pressureVariations of arterial blood pressure
gastro-intestinal symptoms gastro-intestinal symptoms Mimikin acute abdomenaMimikin acute abdomenaJaundice (index of severity)Jaundice (index of severity)
Graves diseaseGraves disease Most frequent cause of hyperthyroidism Most frequent cause of hyperthyroidism
Prevalence 1%Prevalence 1% 19/1000 19/1000 ♀♀ 1,6/1000 1,6/1000 ♂♂ (Sex ratio 7 / 10) (Sex ratio 7 / 10)
Incidence 2 - 3 cases / year /1000 Incidence 2 - 3 cases / year /1000 ♀♀ Young female patient, psychological Young female patient, psychological
traumatrauma Autoimmune, familialAutoimmune, familial
Asociated with other autoimune diseases: Asociated with other autoimune diseases: tip 1DM, adrenal insufficiency, vitiligo, miastenia tip 1DM, adrenal insufficiency, vitiligo, miastenia
gravisgravis Stimulating immunoglobulinsStimulating immunoglobulins
perspiration
amiotrophie
< 40 yearsLymp node enlargement
dispnea
Gynecomastia in ♂♂
flushes
Weigh loss
oligo/amenorrea
Local mixedoema
nervosness, emotional instability
exophtalmos
goiter (± thrill)
Hot, mois skinpalpitations, tachicardia, low response to digytalis
apetit diarheeatremor
acropachia
Muscle weakness, fatigability
Graves’ diseaseGraves’ disease
Graves’ Graves’ diseasedisease
goitergoiter
Graves’ diseaseGraves’ disease
GOITERGOITER DifuseDifuse ElasticElastic Homogenous Homogenous painless painless Vascular (thrill)Vascular (thrill)
Graves exophtalmosGraves exophtalmos
Graves ophtamopathyGraves ophtamopathy
Eyelid edema, periorbital edema, proptosisEyelid edema, periorbital edema, proptosis Increase tears production Increase tears production Incomplete close eyelids during nightIncomplete close eyelids during night Fotofobia, Fotofobia, Eye disconfort, pruritus, “alergyEye disconfort, pruritus, “alergy Painfull eyes, associated or not with eye mouvmentsPainfull eyes, associated or not with eye mouvments Dyplopia Dyplopia
Intermitent: when patinets is tired Intermitent: when patinets is tired InconstantInconstant Constant: when reading Constant: when reading
Graves ophtalmopathy Graves ophtalmopathy NOSPECSNOSPECS
ClassClass DefinitionDefinition
00 NNo phisical signs and symptomso phisical signs and symptoms
11 OOnly signs, no symptoms nly signs, no symptoms (upper lid retraction, stare, proptosis to 22 cm)(upper lid retraction, stare, proptosis to 22 cm)
22 SSoft tissue involvement (symtpoms and signs)oft tissue involvement (symtpoms and signs)
33 PProptosis > 22 cmroptosis > 22 cm
44 EExtraocular muscle involvementxtraocular muscle involvement
55 CCorneal involvementorneal involvement
66 SSight loss (optic nerve involvement)ight loss (optic nerve involvement)
Severity of Graves Severity of Graves ophtalmopathyophtalmopathy
Degree Degree Signs and symptomsSigns and symptoms
EUGOGOEUGOGO (European Group on Graves’ (European Group on Graves’ Orbitopathy)Orbitopathy)
Mild Mild
1.1. Minimal or moderate edemaMinimal or moderate edema2.2. Proptosis <25 mm Proptosis <25 mm 3.3. Diplopia: absent or intermitent Diplopia: absent or intermitent 4.4. No optic nerve envolvement No optic nerve envolvement
Moderate Moderate
Important edeme Important edeme 1.1. And/or proptosis >25 mm And/or proptosis >25 mm 2.2. And/or inconstant dyplopiaAnd/or inconstant dyplopia3.3. And/or corneal point lesions And/or corneal point lesions 4.4. No optic nerve involvement No optic nerve involvement
SevereSevere Constant dyplopiaConstant dyplopia1.1. And/or optic nerve involvement And/or optic nerve involvement
Clinical Activity Score (CAS)Clinical Activity Score (CAS)
1.1. Spontaneous retroocular painSpontaneous retroocular pain
2.2. Pain at eye mouvments Pain at eye mouvments
3.3. Eyelid erithema Eyelid erithema
4.4. Corneal increased vascularity Corneal increased vascularity
5.5. Chemosis Chemosis
6.6. Edema of caruncula Edema of caruncula
7.7. Eyelid edemaEyelid edema Every item has 1 point. Active Every item has 1 point. Active
ophtalmopathy: >3 poinsophtalmopathy: >3 poins
Graves’ ophtalmopathyGraves’ ophtalmopathyEyelid retractionEyelid retraction
Graves’ ophtalmopathyGraves’ ophtalmopathy
Eyelid edemaEyelid edema
Graves’ ophtalmopathyGraves’ ophtalmopathy
Superioar eyelid edemaSuperioar eyelid edema
Eyelid edemaEyelid edema
Graves’ ophtalmopathyGraves’ ophtalmopathy
Enlarged eyelid opening Enlarged eyelid opening
Graves’ ophtalmopathyGraves’ ophtalmopathy
Graves’ ophtalmopathyGraves’ ophtalmopathy Corneal involvmentCorneal involvment
Corneal and conjunctival problemsCorneal and conjunctival problems
Graves’ ophtalmopathyGraves’ ophtalmopathy
Graves’ ophtalmopathyGraves’ ophtalmopathy
Exophtalmos Exophtalmos
Graves’ ophtalmopathyGraves’ ophtalmopathy
Exophtalmos Exophtalmos
OphtalmoplegiaOphtalmoplegia
Graves’ ophtalmopathyGraves’ ophtalmopathy
Graves’ ophtalmopathyGraves’ ophtalmopathy
CT of orbotal areaCT of orbotal area
Graves’ ophtalmopathyGraves’ ophtalmopathy
Pretibial mixoedemaPretibial mixoedema Nodous eritemaNodous eritema
Acropachy Acropachy
Toxic adenoma (Plummer)Toxic adenoma (Plummer) Isolated Isolated
thyroid nodulethyroid nodule autonomousautonomous
Extranodular Extranodular parenchima is parenchima is not functioningnot functioning
TSH levelAutonomous secretion
Normal secretion
TSH
Normal secretion
Autonomous functioning tissue
32 541
32 541
Evolutia Evolutia adenomuadenomu
ui toxicui toxic
Toxic multinodular goiterToxic multinodular goiter
Hearth signs and symptoms are Hearth signs and symptoms are dominantdominant10 - 15 % of atrial fibrillation in 10 - 15 % of atrial fibrillation in
aged patients is associated with aged patients is associated with TMGTMG
Hearth failureHearth failure Compressive goiterCompressive goiter
Subacute thyroiditisSubacute thyroiditis Neck pain Neck pain Tirotoxicosis Tirotoxicosis Post viral Post viral Trifase evolutionTrifase evolution
hyperthyroidismhyperthyroidism hypothyroidismhypothyroidism euthyroidismeuthyroidism
HipoechogenicityHipoechogenicity inhomogenousinhomogenous Pseudo nodularPseudo nodular
Absence of iodine Absence of iodine uptake and “white uptake and “white scintigram”scintigram”
eutiroidism
hipertiroidism
hipotiroidism
HYPERTHIROIDISM / THYROTOXICOSISHYPERTHIROIDISM / THYROTOXICOSISAge-related characteristicsAge-related characteristics
NewbornsNewborns• neonatal Graves disease (goiter exophtalmos, neonatal Graves disease (goiter exophtalmos, thyrotoxicosis)thyrotoxicosis)
• temporarlytemporarly• permanentpermanent
• familial non-autoimmune thyrotoxicosisfamilial non-autoimmune thyrotoxicosis
ChildrenChildren• Graves diseaseGraves disease
• increased growth rateincreased growth rate
Aging patientsAging patients•Toxic adenoma / TMNG / GravesToxic adenoma / TMNG / Graves
• clinical signs are less obvious clinical signs are less obvious • suspected whensuspected when
• it is an unexpected weight lossit is an unexpected weight loss• atrial fibrilation and hearth failure atrial fibrilation and hearth failure unresponssive to digitalisunresponssive to digitalis
O
C
O
C4H9
O CH2 CH2 NC2H5
C2H5
I
Iamiodarona
Amiodarona si tiroidaAmiodarona si tiroida
Celular Celular : : se opune intrarii tiroxinei se opune intrarii tiroxinei si fixarii T3 de receptorii nuclearisi fixarii T3 de receptorii nucleari
Hipofiza tireotropa :Hipofiza tireotropa : TSH us in prima saptamina fara hipotiroidieTSH us in prima saptamina fara hipotiroidie
Tiroida: Tiroida: acumulare de iod - efect Wolf Chaikoffacumulare de iod - efect Wolf Chaikoff citotoxicitate foliculairacitotoxicitate foliculaira
Periferic Periferic : : conversie T4 in T3 (inhiba 5’ deiodaza)conversie T4 in T3 (inhiba 5’ deiodaza)
manifestari tirotoxice putin marcatemanifestari tirotoxice putin marcate
Amiodarone –induced hyperthyroidismAmiodarone –induced hyperthyroidism
Type I : Type I : hyperfunctional hyperfunctional
(previous thyroid (previous thyroid autoimmunity)autoimmunity)
Type II : distructive Type II : distructive (previous normal (previous normal
thyroid)thyroid)
Affected Affected individualsindividuals women 1/2women 1/2 men 2/3men 2/3
123123I uptakeI uptake N, N, Scintigram positiveScintigram positive
absenteabsenteScintigram absentScintigram absent
IL6IL6 NormalNormal and and Tg Tg
Ultrasound Ultrasound volumevolume Normal volumeNormal volume
EchodopplerEchodoppler Hypervascularity Hypervascularity (grad 1-3)(grad 1-3)
Hipoechoic, Hipoechoic, hipovascular (grad 0)hipovascular (grad 0)
Classic Classic treatmenttreatment
ATS 6-9 monthATS 6-9 monthKCLO4 Potasium KCLO4 Potasium
perclorateperclorateGlucocorticoidsGlucocorticoids
PrognosisPrognosis
Sponaneous regression Sponaneous regression (3-6 month)(3-6 month)Prolonged Prolonged
hyperthyroidismhyperthyroidism
Spontaneous Spontaneous regression (3-6 month)regression (3-6 month)
Transitory Transitory hypothyroidismhypothyroidism
Thyrotoxicosis treatmentThyrotoxicosis treatment1.1. AIM: to decrease thyroid hormones to AIM: to decrease thyroid hormones to
normal levelsnormal levels Distruction of thyroid Distruction of thyroid
surgerysurgery Radio iodineRadio iodine
Inhibition of thyroid hormone synthesis Inhibition of thyroid hormone synthesis (ATD)(ATD)
Antithyroid drugsAntithyroid drugs Glucocorticoids adjuvant therapyGlucocorticoids adjuvant therapy
2.2. Decreases conversion of T4 to T3 Decreases conversion of T4 to T3 3.3. inhibitioninhibition
ATDATD glucorticoids (high doses)glucorticoids (high doses) propranololpropranolol iodineiodine
Reduction of receptor couplingReduction of receptor coupling -blokers-blokers plasmaferesisplasmaferesis
Antithyroid drugsAntithyroid drugsImidazole derivatives (methimasole)Imidazole derivatives (methimasole)
NN
HH
NHNH
SS
OO
Thyourheea derivatives Thyourheea derivatives (thiouracile)(thiouracile)
NN
HHCHCH33-CH-CH22-CH-CH22
NHNH
SS
OO
carbimasolecarbimasole
propilthiouracilepropilthiouracile
Inhibit TPOInhibit TPO
Inhibits TPOInhibits TPOInhibits type Inhibits type 1deiodinase1deiodinase
NHNH
NN SS
HH
NNCOOCCOOC22HH55
NN SS
HH
Treatment of hypothyroidism ATDTreatment of hypothyroidism ATD
2 possibilities2 possibilities Continous high dosage and association Continous high dosage and association
ofthryoid drugs when hypothyroidism ofthryoid drugs when hypothyroidism occursoccurs
Decreasing dosage to the minimal dosage Decreasing dosage to the minimal dosage that maintans an euthyroid statethat maintans an euthyroid state
Graves diseaseGraves disease Young womenYoung women 1,5 years at least1,5 years at least Monitoring the resullts TS-AbMonitoring the resullts TS-Ab < 50%cure< 50%cure
in toxic adenoma /GMNT in toxic adenoma /GMNT Only a temporary solution Only a temporary solution
Antithyroid drugsAntithyroid drugs
DosageDosage Adults 10-20 mg x 2 po initiallyAdults 10-20 mg x 2 po initially
Dosage will be decreased to ½ doza Dosage will be decreased to ½ doza when patient becomes euthyroid when patient becomes euthyroid
Children: 15-20 mg/mChildren: 15-20 mg/m22 divided in 2 divided in 2 doses initial;ydoses initial;yLater: minomal efficient doseLater: minomal efficient dose
Treatment of hyperthyroidismTreatment of hyperthyroidismother possibilitiesother possibilities
LitiumLitium inhibits TPOinhibits TPO high toxicityhigh toxicity
Stable Iodine Stable Iodine Lugol solution Lugol solution
1 g iodne1 g iodne2 g KI2 g KI20 ml distilated 20 ml distilated
waterwater Preoperative for Preoperative for
surgerysurgery 3 × 20 picături pe zi, 3 × 20 picături pe zi,
10-14 zile10-14 zile
Nodule necrosis Nodule necrosis with alcohol with alcohol toxic adenomatoxic adenoma
Potassium Potassium perclorateperclorate amiodarone amiodarone
inducedinduced thyrotoxicosis thyrotoxicosis
Antiimflamatory Antiimflamatory drugsdrugs subacute subacute
thyroiditisthyroiditis Type II amiodarone Type II amiodarone
inducedinduced
100100
RIU RIU 123123I (24 h)I (24 h)thyroidthyroid
wight (g)wight (g)80-100 mCi/g 80-100 mCi/g 131131II xx xx
radioactive iodineradioactive iodine: Graves disease: Graves disease
T4I*
TSH
Radioactive iodineRadioactive iodine: toxic adenoma: toxic adenoma
SurgerySurgery
Graves diseaseGraves disease tyroidectomy (near) tyroidectomy (near)
totaltotal indicationsindications
Increased thyroid Increased thyroid nodulenodule
GMNTGMNT tyroidectomy tyroidectomy
(near)total (near)total adenomul toxicadenomul toxic
lobectomylobectomy
Complications Complications hypothyroidism hypothyroidism hypoparathyroidishypoparathyroidis
me (3-5%)me (3-5%) laringeal nerve laringeal nerve
paralisisparalisis hemorrhage hemorrhage
during surgeryduring surgery
GRAVESGRAVESOPHTALMOPATHYOPHTALMOPATHY
Total thyroidectomy or ATDTotal thyroidectomy or ATD + terapie prednisone ! + terapie prednisone !
10 mg x 4 – 7d10 mg x 4 – 7d
Form of ophtalmopathy?Form of ophtalmopathy? recente –immunosupressiverecente –immunosupressive
prednisone 25 mg x 4, 7-14 dprednisone 25 mg x 4, 7-14 d metilprednisolone 250 iv, repeated at 3 days metilprednisolone 250 iv, repeated at 3 days
(pulse)(pulse) Polyclonal immunoglobulins Polyclonal immunoglobulins
old (GAG infiltration, fibrosis)old (GAG infiltration, fibrosis) Retroorbitar irradiationRetroorbitar irradiation enlargement of the orbitisenlargement of the orbitis surgery on orbital musclessurgery on orbital muscles other plastic surgery proceduresother plastic surgery procedures
Tratamentul exoftalmiei basedowieneTratamentul exoftalmiei basedowieneDecompresie orbitaraDecompresie orbitara
Inainte Dupa tratament
Graves ophtalmopathyGraves ophtalmopathyOrbital decompressionOrbital decompression
Before After treatment
Thyreotoxic crisisThyreotoxic crisisObjectives Objectives I.I. Inhibition of thyroid hormone synthesis Inhibition of thyroid hormone synthesis
and liberationand liberationII.II.Decreased action of thyroid hormones on Decreased action of thyroid hormones on
target tissuestarget tissues Reduction of thyroid hormone concentrationReduction of thyroid hormone concentration Conversion inhibition of TConversion inhibition of T44 into T into T33
Adrenergic blokadeAdrenergic blokade
III.Treatament of systemic symptomsIII.Treatament of systemic symptoms feverfever dehydrationdehydration supportivesupportive
IV.Treatament of precipitating factorsIV.Treatament of precipitating factors
Thyrotoxic crisisThyrotoxic crisis
Inhibiton of hormone synthesisInhibiton of hormone synthesisAntithyroid drugs (ATD) Antithyroid drugs (ATD)
Large doses, per osLarge doses, per osPropiltiouracilePropiltiouracile (PTU) - 1200 - 1500 mg/d (200-250mg la 4h); (PTU) - 1200 - 1500 mg/d (200-250mg la 4h);MethimasoleMethimasole (MMI) - 120 mg/d (20 mg la 4h); (MMI) - 120 mg/d (20 mg la 4h);
Inhibition of TH liberationInhibition of TH liberation Iodine-containing compaundsIodine-containing compaunds
Lugol sol; saturate solution of KILugol sol; saturate solution of KI (SSKI) -p.o., 5 drops every 6h; (SSKI) -p.o., 5 drops every 6h;Contrast media Contrast media (inhibition of conversion of T (inhibition of conversion of T44 into T into T33):):
Criza tireotoxicaCriza tireotoxica
Inhibition of peripheral conversion T4 to T3Inhibition of peripheral conversion T4 to T3propilthyouracil; ipodate, iopanoate; propranolol; propilthyouracil; ipodate, iopanoate; propranolol;
glucocorticoidsglucocorticoidsAdrenergic blokade:Adrenergic blokade:
betablokers betablokers - propranolol – most used:- propranolol – most used: iv, large doses iv, large doses short-action blokers (labetalol, esmolol);short-action blokers (labetalol, esmolol);
reserpine, guanetidine:reserpine, guanetidine:utile în contraindicaţiile utile în contraindicaţiile -blocantelor;-blocantelor;
Removal of thryoid hormone excess Removal of thryoid hormone excess plasmapheresis;plasmapheresis;dialysisdialysis
II. Reduction of TH action on target tissuesII. Reduction of TH action on target tissues
Thyrotoxic crisisThyrotoxic crisis
Treatment od Treatment od systemic systemic symptomssymptoms
feverfeverCoated with cold Coated with cold sheetssheets
drugsdrugsparacetamole paracetamole
DihydrationDihydration heath failureheath failure glucocorticodsglucocorticods
IV. Treatment of IV. Treatment of precipitating precipitating factorsfactors